Strabismus In Adults Research Articles

Extraocular Muscle Transplantation Surgery for Primary Treatment of Extra Large-angle Squint.

Large-angle horizontal ocular deviations will commonly require bilateral surgery to correct the primary ocular deviation. However, considering the need for full correction with one surgical procedure and patients' reluctance to be operated on the good eye, such large horizontal ocular deviations may be managed with true muscle transplantation. The authors present a case series of patients who underwent this procedure and develop a surgical table to guide management. Patients with horizontal squints measuring 80 prism diopters (PD) or larger in all age groups who underwent extraocular muscle transplantation surgery between January 2019 and June 2022 in Nigeria were included. Preoperative deviation of the squint, sensory evaluation, surgical dosage, and outcomes were documented. Part of the resected muscle was transplanted to give additional recession in the antagonist muscle. Success was defined as deviation corrected by 60% or more or postoperative ocular alignment within 10 PD or less, six weeks postoperatively. Fourteen patients with extra-large-angle strabismus were operated. Male/female ratio was 0.6:1. Mean preoperative deviation of 89.6 9.3 collapsed to 6.6 1.8 PD at six weeks and continued to improve to a mean deviation of 2.5 PD at six months postoperatively. When the subgroup of patients who were 18 years were analyzed, the outcome was equally successful; preoperative deviation of 89.4 PD collapsed to 1.4 PD, six months postoperatively. There were equal success rates when those with sensory strabismus were compared with those with binocular vision; preoperative deviation of 92.5 PD in the sensory group and 88.5 PD in the binocular group collapsed to 5.9 PD and 1 PD, respectively, six months after surgery. A viable alternative for treating extra-large-angle strabismus in adults and children in developing countries was described with good postoperative outcome. In addition, a new expanded surgical dosage table for muscle transplantation surgery corrections of up to 130 PD was developed.

Prevalence of strabismus and risk factors in adults born preterm with and without retinopathy of prematurity: results from the Gutenberg Prematurity Eye study

AimThe purpose of this study was to assess the prevalence of strabismus and nystagmus and to analyse associated factors in preterm and full-term infants in adulthood.MethodsThe Gutenberg Prematurity Eye Study...

SUCESSFULL MANAGEMENT OF CHILDHOOD BASIC-TYPE ESOTROPIA IN ADULT PATIENT

Introduction : Strabismus in adults may indicate other pathological causes, such as neurological disorders or trauma. Diagnosis of esotropia in adult patients has to be made carefully to determine the right treatment. Management’s goal of strabismus in adult patients is mainly cosmetic by diminishing deviation.
 Case Illustration : A 46-year-old woman, complaint of inward deviation of both eyes since childhood. There were no complaints of double vision, headaches, nor trauma history. Visual acuity of right eye was 0.4 with BCVA and left eye was 0.8 with BCVA 0.8. Hirschberg test was 45o (Figure 2A). Prism cover test was 75 PD base out in near and distance. Patient was diagnosed with basic-type esotropia. The patient already given spectacles but the deviation persisted so she underwent bilateral medial rectus recess surgery (Figure 2B). Ocular alignment without spectacles 1 week after surgery showed orthotropia and small esophoria. (Figure 2C).
 Discussion : Each esotropia types has a different treatment approach. Basic-type esotropia with large deviation usually needs surgical treatment. Management of childhood onset strabismus in adult patients is challenging because those patients have lesser ability to maintain fusion. Older patients and large deviation are poor prognostic factors to achieve good functional and cosmetics outcome after strabismus surgery.
 Conclusion : Establishing a definite diagnosis in adult strabismus patients, including esotropia, is challenging. Careful diagnosis and management decision will determine the outcome of the patient’s condition.

Prevalence and Incidence of Strabismus by Age Group in Japan: A Nationwide Population-Based Cohort Study

To investigate the prevalence and incidence of strabismus in the Japanese population by age group and to estimate the subtype proportions. A nationwide population-based cohort study. This study investigated the number of cases with previous and new diagnoses of strabismus by age group between 2009 and 2020 using the National Database of Health Insurance Claims and Specific Health Checkups of Japan, which includes almost all (≥95%) medical claims data. We calculated the strabismus prevalence and 1-year incidence in 2019 and analyzed the proportion of each strabismus subtype. The strabismus prevalence was 2.154% (2 709 207/125 708 000; 95% CI, 2.152%-2.157%). It showed a bimodal distribution, with a high proportion in school and old ages (especially ≥75 years). Exotropia, esotropia, and cyclovertical strabismus proportions were 67.3%, 26.0%, and 6.7%, respectively. Cyclovertical strabismus was uncommon in patients aged ≤18 years (1.4%) and more common (10.2%) in those aged >18 years. The strabismus incidence in 2019 was 321 per 100 000 person-years (403 093/125 708 000; 95% CI, 320-322). The annual incidence proportion of cyclovertical strabismus as opposed to whole strabismus subtypes in patients aged >18 years (13.1%) was higher than that in those aged ≤18 years (1.4%). This is the first nationwide population-based cohort study to demonstrate strabismus's overall prevalence and incidence. The high prevalence of cyclovertical strabismus in adults compared with children may suggest that cyclovertical strabismus is a primarily age-related strabismus. The high prevalence of exotropia may indicate a genetic difference between Japanese and other ethnicities.

Slab-off prism for symptomatic, vertical heterophoria in the reading position

To describe uncommon techniques that induce compensatory strabismus utilizing slab-off spectacle prism to treat symptomatic incomitant vertical strabismus in adults with diplopia in the reading position only. The medical records of consecutive patients having a chief complaint of diplopia in the reading position that was treated with slab-off prism correction were reviewed retrospectively. Success of the slab-off spectacle prism correction was determined at the follow-up visit or by phone call for any patients who did not return for a follow-up examination. Five adult subjects were identified, ranging in age from 55 to 75 years (mean age, 65.6 years). All 5 patients complained of vertical diplopia during reading. Symptoms resolved with slab-off prism in all 5 cases. Three patients had symptomatic incomitant vertical strabismus occurring only in the reading position. All 3 of these patients remained in slab-off prism at in-office follow-up. Slab-off spectacle prism in non-digitally manufactured multifocal lens prescriptions was an effective nonsurgical treatment option in this descriptive study of 5 patients with diplopia in the reading position only, 3 of whom had symptoms related to small-angle vertical strabismus in the reading position only, without anisometropia.

Phased strabismus surgery under topical anesthesia.

To evaluate the feasibility and outcomes of phased strabismus surgery under topical anesthesia, with intraoperative comparison of ocular alignment in supine and seated positions. This retrospective clinical investigation analyzed the data of patients who underwent phased strabismus surgery with fixed sutures under topical anesthesia. The technique consisted of 2 phases, spaced out with an intraoperative alternate prism cover test (performed in supine and seated positions): (1) surgery on one or two muscles, as defined by a preoperative surgical plan; (2) if judged necessary, a further one-muscle surgery. Surgical success was defined as a residual angle of horizontal and vertical deviation ≤±8Δand ≤5Δ, respectively, and the presence of single binocular vision in primary position in patients with preoperative diplopia. Follow-up visits were scheduled 1 day, 1 month, and 6 months after surgery. The review identified 38 patients (age range: 10-80 years). Surgery was well tolerated by all patients. Twelve (32%) required a second phase. No statistically significant differences were found for intraoperative angles of deviation in supine and seated positions. Surgical success was reached, respectively, in 88% and 87% of cases with horizontal and vertical deviation 6 months after surgery. No patients were reoperated during the follow-up period. Phased strabismus surgery is a feasible technique for various types of strabismus in adults and children. Secondly, intraoperative evaluation of ocular alignment can be performed either with the patient seated or supine, with the same accuracy in terms of surgical success.

The Effect of Surgical Treatment of Horizontal Strabismus on Refractive Changes in Adult Patients

Concomitant strabismus and refractive anomalies are often common pathological conditions in adult patients. The patient’s desire to get rid of both problems poses a question to the surgeon about the order of surgical interventions. With non-accommodative concomitant strabismus, the question is not so unambiguous. Despite a significant number of studies devoted to this topic, there is still no unequivocal opinion on the significance of refractive error after strabismus surgery. Thus, it remains an urgent task to study of possible surgically induced refractive changes after interventions on extraocular muscles and their assessment during the observation period.Purpose. Evaluation of the effect of surgical treatment of horizontal strabismus in adults on refractive and astigmatic status.Patients and methods. A prospective study of 30 patients with concomitant convergent or divergent strabismus. Each patient underwent surgery for horizontal strabismus, which consisted in recession and resection of the extraocular muscles of one eye. The spheroequivalent (SE) and cylinder (Cyl) values were determined before surgery, 1, 3, and 6 months after surgery. Refractive changes were calculated in the postoperative period, both for the spheroequivalent and for the cylinder, after 1 month (SIRC1), 3 months (SIRC2) and 6 months (SIRC3). In addition, the difference (d) between SIRC1 and SIRC3 was calculated to determine if they were temporary or permanent. Analysis of the induced changes in the magnitude and direction of astigmatism was performed using vector analysis.Results. The dynamics of SE values within 6 months after surgery shifted to insignificant myopia, however, no significant static difference in this parameter was found (p = 0.17). The mean change in spherical equivalent (SE) refraction was 0.22 ± 0.47 diopters in SIRC1, 0.15 ± 0.44 diopters in SIRC2, and 0.12 ± 0.51 diopters in SIRC3. There was no statistically significant difference between changes in surgically induced refraction at different times after surgery (p = 0.34). The difference (SIRC d) between SIRC1 and SIRC3 for the spheroequivalent was 0.096 ± 0.480 and can be interpreted as a decrease in surgically induced refraction error within 6 months after surgery. Surgically induced astigmatism at different times after surgery was: SIRC1 = 0.44 ± 0.39, SIRC2 = 0.47 ± 0.41, SIRC3 = 0.43 ± 0.29. There was no statistically significant difference in this parameter during the study period (p = 0.1). The difference (SIRC d) between SIRC1 and SIRC3 for astigmatism was 0.0001 ± 0.3200, which indicates stable values of astigmatism. According to the vector analysis, the magnitude and axis of preoperative astigmatism was 1.131 ± 0.410 ax172 and is close to the actual postoperative values of 1.17 ± 0.50 ax172. The vector of surgically induced astigmatism was 0.43 ± 0.10 ax84. These changes were not statistically or clinically significant.Conclusion. In general, the refractive and astigmatic status does not change after surgical treatment of horizontal strabismus. However, in this study, there was a myopic refraction shift during the first 3–6 months after surgery. In this connection, it is possible to recommend refractive operations to adult patients 3–6 months after strabismus surgery.

Long-term outcomes of adjustable strabismus surgery at a Pakistani university hospital.

Strabismus, whether congenital or acquired, is a common visual and cosmetic problem, especially for the young. Adjustable suture strabismus surgery is not in vogue in our country. This technique gives the surgeon a second attempt to provide a better outcome for the patients. Our objective was to assess the long-term success of adjustable strabismus surgery in terms of postoperative alignment. We carried out a prospective study utilizing the fornix approach for adjustable strabismus surgery, in mainly horizontal, but also vertical strabismus in adults and cooperative children, to enhance the postoperative outcomes. The patient characteristics, preoperative deviation, type and pattern of strabismus, were evaluated and analyzed. The postoperative alignment was evaluated at 1year and beyond, to assess the success of this adjustable surgery. This study recruited 50 adults and children with a female predominance of 39 (78%); and with the mean age being 18.34 ± 9.88years. Exotropia was the primary diagnosis in the majority with 21(42%) cases; with purely horizontal strabismus in 23(46%) cases. The mean preoperative horizontal deviation was 48.76 ± 20.35prism diopters (PD) and the mean postoperative horizontal deviation was 2.73 ± 3.63 PD. The mean preoperative vertical deviation was 4.8 ± 8.54 PD whereas the mean postoperative vertical deviation was 0.86 ± 1.73 PD. The Wilcoxon Signed Ranks test analyzed the difference between the two which was statistically significant (p = 0.000). Surgical success, defined as postoperative horizontal alignment within ≤ 10 PD of orthotropia at the end of one year or more of follow-up after surgery, was achieved in 49 (98%) cases. The average follow-up was 21.47 ± 8.7months. Adjustable strabismus surgery has very good long-term outcomes in terms of postoperative alignment and patient satisfaction.

Efficacy and safety of adjustable suture in horizontal strabismus: Comparative study of children versus adults

ObjectiveAdjustable suture procedures allow addressing the unpredictability of some postoperative results in strabismus surgery. The purpose of the study was to compare the effectiveness of adjustable and non-adjustable suture in the treatment of horizontal strabismus in children and adults. MethodsProspective study including patients undergoing strabismus surgery to correct horizontal strabismus with fixed hanging suture (non-adjustable suture group) and adjustable suture. Visual acuity, amblyopia, deviation, oblique muscle involvement, previous surgeries, nystagmus, need for adjustment, and complications were recorded. The variables were recorded in the immediate postoperative period, at one week and at 3 and 6 months. Results186 patients were included: 157 (84.4%) with adjustable suture and 29 (15.6%) with non-adjustable suture, of which 119 were children and 67 were adults. Postoperatively, 19 children (16.0%) and 19 adults (28.4%) required adjustment (p = 0.044). Of 157 patients with adjustable suture, it was adjusted in 20% (32/157). Success after adjustment was higher for adjustable suture (91.72% vs 79.31%; p = 0.043) and remained for 6 months (p < 0.05). Previous surgery (p = 0.004) and exotropia (p = 0.018) correlated with the need for adjustment. Conclusions20% of patients with horizontal strabismus can benefit from a postoperative adjustment to improve the surgical result. The adjustable suture was shown to be superior to the fixed hanging suture and is an excellent surgical option, both in children and adults.

Результаты оперативного лечения содружественного косоглазия у взрослых в амбулаторных условиях

Aim. To evaluate the effectiveness of surgical treatment of concomitant strabismus in adult patients on an outpatient basis. Methods. 73 patients (73 eyes) with a diagnosis of concomitant strabismus without a paralytic component, aged from 19 to 62 years, were under observation. All patients underwent surgical treatment of strabismus for cosmetic purposes. Results. A decrease in the deviation angle was achieved in all patients. The state of orthotropy was obtained in 58 (79.5 %) patients. Conclusions. Surgical treatment of strabismus makes it possible to achieve the correct position of the eyeballs and a good cosmetic effect in 80 % of cases with a one-stage intervention and 94.5 % with a phased surgical treatment. Observation of patients in the long term (3 years) revealed a fairly persistent cosmetic effect of the intervention. Key words: strabismus in adults; strabismus surgery.

Eficacia y seguridad de la sutura ajustable en estrabismos horizontales: estudio comparativo de niños frente a adultos

ObjectiveAdjustable suture procedures allow addressing the unpredictability of some postoperative results in strabismus surgery. The purpose of the study was to compare the effectiveness of adjustable and non-adjustable suture in the treatment of horizontal strabismus in children and adults. MethodsProspective study including patients undergoing strabismus surgery to correct horizontal strabismus with fixed hanging suture (non-adjustable suture group) and adjustable suture. Visual acuity, amblyopia, deviation, oblique muscle involvement, previous surgeries, nystagmus, need for adjustment, and complications were recorded. The variables were recorded in the immediate postoperative period, at one week and at 3 and 6months. Results186 patients were included: 157 (84.4%) with adjustable suture and 29 (15.6%) with non-adjustable suture, of which 119 were children and 67 were adults. Postoperatively, 19 children (16.0%) and 19 adults (28.4%) required adjustment (P=.044). Of 157 patients with adjustable suture, it was adjusted in 20% (32/157). Success after adjustment was higher for adjustable suture (91.72% vs 79.31%; P=.043) and remained for 6months (P<.05). Previous surgery (P=.004) and exotropia (P=.018) correlated with the need for adjustment. Conclusions20% of patients with horizontal strabismus can benefit from a postoperative adjustment to improve the surgical result. The adjustable suture was shown to be superior to the fixed hanging suture and is an excellent surgical option, both in children and adults.

Outcomes of a simplified, fixed surgical dosage calculation for uncomplicated, horizontal, concomitant strabismus in adults.

Purpose:The aim of this study was to evaluate the outcomes of a simplified, fixed surgical dosage calculation for uncomplicated, horizontal, concomitant strabismus in adults.Methods:Outcomes analysis of a fixed-dose calculation method for uncomplicated, horizontal, concomitant strabismus in adults (≥18 years) wherein 1-mm recession/resection equals 2 PD for lateral rectus and 3 PD for medial rectus. This was a retrospective case series.Results:The mean age of the patients was 28.50 ± 8.43 years, the mean amount of preoperative deviation was 35.16 ± 9.97 PD, the mean expected correction was 36.26 ± 9.49 PD, and the mean correction achieved was 35.92 ± 10.74 PD. There were 22 monocular exotropias, six monocular esotropias, eight alternate divergent squints, and two alternate convergent squints. There were 20 cases of sensory strabismus (54.28%). There was no statistically significant difference between the expected correction and correction achieved (P = 0.519), meaning that our fixed-dose calculation method was effective. Thirty-five out of 38 patients had successful outcomes as per our criteria of less than 10-PD deviations from straight in primary position. Therefore, the success rate achieved by this procedure was 92.10%. There was no statistically significant correlation between age and the amount of deviation (P = 0.611)Conclusion:Our case series had a high postoperative success rate in terms of motor alignment. It is hoped that this simplified, fixed-dosage calculation method would help the numerous novice strabismus surgeons, make their starting steps easier and give them the confidence to do strabismus surgeries. They can modify the dosages later as per their own experiences.

Trends in Etiologies, Demographics, and Neuroimaging in New-Onset Adult Strabismus at an Ophthalmic Emergency Department.

To evaluate new-onset strabismus in adults presenting to an ophthalmic emergency department, and to identify which patients require neuroimaging. This was a retrospective review of electronic medical records of patients 18 years and older who presented to an ophthalmic emergency department between January 1, 2019 and December 31, 2020 with new-onset strabismus. Data regarding demographics, causes, neuroimaging, and resolution were recorded and analyzed. Of the 557 patients in the current study, 54.8% were men and the mean age was 57.3 ± 16.7 years (range: 18 to 92 years). Most patients (72.4%) presented with diplopia. Esotropia was the most common ocular misalignment (43.6%) and was more common in women than men (51.6% vs 37.0%, respectively) (P = .001). The most common diagnoses were cranial nerve palsies (66.8%) for both sexes and all age groups, with the most common etiology being microvascular (48.1%) for patients 50 years and older and idiopathic (20.1%) for patients between 18 and 49 years old. The incidence of cranial nerve palsies was significantly higher in older patients (P < .001). Neuroimaging was performed in 58% of patients (n = 323), of whom 37.2% (n = 120) had abnormal findings. The most common abnormal neuroimaging finding was mass for all age groups and sexes (19.2%). Patients with cranial nerve palsy and microvascular etiology had a significantly lower proportion of abnormal neuroimaging findings (P < .001). Most cases of new-onset strabismus in adults presenting to the emergency department were due to cranial nerve palsy, particularly in older patients. Despite high rates of neuroimaging, patients with cranial nerve palsy had mostly normal findings. The current study supports the belief that neuroimaging may be deferred in patients older than 50 years with micro-vascular risk factors. [J Pediatr Ophthalmol Strabismus. 2022;59(4):269-273.].

Strabismus, stereoacuity, accommodation and convergence in young adults born premature and screened for retinopathy of prematurity.

The aim of the study was to evaluate strabismus, stereoacuity, accommodation and convergence in prematurely born young adults; screened for retinopathy of prematurity in the neonatal period and compare with term-born individuals of the same age. The study participants included 59 prematurely born individuals with a birthweight of ≤1,500 grams and 44 term-born controls, all born during 1988-1990 in Stockholm County, Sweden. Ocular alignment was assessed with a cover test, stereoacuity with the TNO stereo test and the amplitude of accommodation and the near point of convergence with the Royal Air Force Rule. Seven of 59 (12%) preterms had manifest strabismus, 4/59 (7%) had esotropia and 3/59 (5%) exotropia. One of 44 (2%) controls had esotropia; no other controls had manifest strabismus. Stereoacuity was within normal limits in 38/59 (64%) preterms and 43/44 (98%) controls, p < 0.01; the difference remained after excluding those with strabismus. A neurological complication at 2.5 years of age was the strongest risk factor for subnormal stereoacuity within the preterm group after excluding those with strabismus. The mean amplitude of accommodation was poorer in the preterms than the controls in better (p < 0.05) and worse eyes (p < 0.05). The preterms were more likely to have an amplitude of accommodation below the minimum, according to Hofstetter's equation. There were no differences between the groups regarding the near point of convergence. Prematurely born young adults had a higher prevalence of strabismus, reduced stereoacuity and worse amplitude of accommodation than term-born controls.

Study of awareness, perception about strabismus and social impact of strabismus in adults attending tertiary care centre

Aim: Strabismus is the common condition seen in children and adults in our society. Strabismus has variety of psychosocial impact that can affect the quality of life of the patients. Proper education and awareness regarding the condition can help to rule out the myths associated with strabismus and also building up the personality of the patients. This study was done to know the level of awareness, knowledge about the strabismus in our population and the social impact of strabismus in patients life. Material and Methods: Cross sectional study conducted on 196 patients with strabismus attending outpatient department of Minto Ophthalmic Hospital, regional institute of ophthalmology were included in the study. After taking informed consent, face to face interview conducted asking questions from structured questionnaire prepared. Data collected and analysed with descriptive statistics. Results: Out of 196 patients included in the patients, 128 were males and 68 females. About 9.6 % of patients, were unaware of the condition of strabismus, 56.3% were unaware that squint can cause visual disturbance, 63% were unaware of that strabismus can be treated, 37% of people felt like surgery is the only mode of treatment for strabismus. 60% of the study population expressed that they were rejected for being married due to strabismus because of cosmetic affect, 42.4% felt like squint can hinder the social leadership, 36 % had difficulty in getting job, 28% of the patients expressed being criticized by their friends that lowered their confidence, 75% of the patients felt that they look ugly because of strabismus. Conclusion: Strabismus apart from causing ocular problems, is associated with many psycho-social impact on life of patients. There is lack of awareness regarding the strabismus in our population. Attitude and perception of society towards patients with strabismus will affect the overall confidence, personality of the patients and hence affect quality of life. Hence awarenes

Late Surgical Correction of Longstanding Constant Strabismus in Adults: Is Fusion Possible in All Successfully Aligned Patients?

ABSTRACT Purpose To determine whether late surgical correction provides fusion in adults who have constant strabismus beginning in early childhood. Materials and Methods This was a prospective study that included 34 consecutive adults with a history of early onset strabismus who had not previously undergone surgery. They were tested with the Bagolini striated glasses (BSG), Worth four-dot (W4D) test, cover test, and four-prism diopter (4-PD) test, preoperatively, and 6 weeks after surgery. Results The mean age was 23.8 years, 17 patients had esotropia and 17 patients had exotropia. Preoperatively, all patients demonstrated a manifest horizontal deviation ranging from 30∆ to 60∆ and had suppression. At 6 weeks postoperatively, 33 patients had a horizontal manifest deviation of <15∆ (range, 2∆-14∆; median, 6∆), and none were orthotropic as determined by the cover test together with the 4-PD test. All of these 33 patients achieved anomalous retinal correspondence (ARC) with the BSG at near, and 25 (75%) had ARC with the W4D test at near. Conclusions Although our study has limited number of patients its findings suggest it is possible to develop ARC after surgery in almost all adult patients with childhood-onset strabismus associated with suppression, and who have not previously been operated upon, if satisfactory alignment is achieved in adulthood.

Techniques and outcomes of strabismus surgery in the setting of glaucoma drainage devices in the pediatric population

Glaucoma drainage devices can worsen strabismus in adults and children, presenting surgical challenges.

The effect of strabismus on the quality of life in adult strabismus patients in Egypt

Purpose The study aims at identifying the main concerns affecting quality of life (QOL) in adult strabismus patients in Egypt. Patients and methods Seventy adults with strabismus, 20 with diplopia and 50 without the disease were recruited. Individual interviews, using 11 open-ended questions, were audiotaped, transcribed, and transcripts reviewed. Phrases regarding how strabismus affected everyday life were grouped into topic areas and the frequency of each topic analyzed for patients with and without diplopia. Results With self-esteem, interpersonal relationships, and social anxiety was not surprising based on previous studies of the psychosocial effects of strabismus in adults. Nevertheless, some concerns identified in this study were more unexpected, for example appearance in photos, education, marriage, and no treatment for squint. Other concerns in this study were unexpected as most of the patients did not express these problems, for example, in-depth perception, driving, and sports. Conclusion Multiple individual interviews have shown many topics which negatively affect the QOL in strabismic adults. The frequency and type of concerns confirm the importance of health-related QOL assessment as an important aspect of strabismus management. Cultural difference resulted in a different pattern of patient responses and health-related QOL concerns.

Surgical interventions for vertical strabismus in superior oblique palsy.

Superior oblique palsy is a common cause of vertical strabismus in adults and children. Patients may be symptomatic from binocular vertical diplopia or compensatory head tilt required to maintain single vision. Most patients who are symptomatic elect to undergo strabismus surgery, but the optimal surgical treatment for vertical strabismus in people with superior oblique palsy is unknown. To assess the relative effects of surgical treatments compared with another surgical intervention, non-surgical intervention, or observation for vertical strabismus in people with superior oblique palsy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 13 December 2016), Embase Ovid (1947 to 13 December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 13 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 13 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 13 December 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 13 December 2016. We did not use any date or language restrictions in the electronic searches for trials. We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation. Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. We identified two randomized trials comparing four different surgical treatments for this condition, two methods in each trial. The studies included a total of 45 children and adults. The surgical treatments were all procedures to weaken the ipsilateral inferior oblique muscle. One study compared inferior oblique myectomy to recession of 10 mm; the other study compared inferior oblique disinsertion to anterior transposition (2 mm anterior to the temporal border of the inferior rectus insertion).We judged both studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Neither study reported data on the primary outcome of this review, which was the proportion of participants with postoperative surgical success, defined as hypertropia less than 3 prism diopters (PD) in primary gaze. However, both studies reported the average reduction in hypertropia in primary gaze. One study found that at 12 months' postoperatively the average decrease in hypertropia was higher in participants who underwent inferior oblique myectomy than in those who underwent recession, however data were not available for statistical comparison. The other trial found that after at least six months of follow-up, the mean decrease in primary position hypertropia was lower in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (mean difference (MD) -5.20 PD, 95% confidence interval (CI) -7.76 to -2.64; moderate-quality evidence).Both trials also reported the average postoperative reduction in vertical deviation in adduction. One study reported that the average reduction in hypertropia in adduction was greater in participants who underwent inferior oblique myectomy than in those who underwent recession, but data were not available for statistical comparison. The other study found a lower decrease in hypertropia in contralateral gaze in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (MD -7.10 PD, 95% CI -13.85 to -0.35; moderate-quality evidence).Secondary outcomes with sufficient data for analysis included proportion of participants with preoperative head tilt that resolved postoperatively and proportion of participants who underwent a second surgery. These outcomes were assessed in the trial comparing inferior oblique anterior transposition to disinsertion; both outcomes favored anterior transposition (risk ratio 7.00, 95% CI 0.40 to 121.39 for both outcomes; very low-quality evidence). None of the participants who underwent inferior oblique anterior transposition or disinsertion developed postoperative hypotropia or reversal of the vertical deviation. All participants who underwent inferior oblique anterior transposition developed elevation deficiency, which the authors deemed to be clinically insignificant in all cases, whereas no participants who underwent inferior oblique disinsertion experienced this complication. Additionally, the trial comparing inferior oblique myectomy to recession reported that no participant in either group required another strabismus surgery during the postoperative period. The two trials included in this review evaluated four inferior oblique weakening procedures for surgical treatment of superior oblique palsy. We found no trials comparing other types of surgical procedures for this disorder. Both studies had enrolled a small number of participants and provided low-quality evidence due to limitations in completeness and applicability. We therefore found no high-quality evidence to support recommendations for optimal surgical treatment of superior oblique palsy. Rigorously designed, conducted, and reported randomized trials are needed to identify the optimal surgical treatment for vertical strabismus in this disorder.

Validation de la version française d’un questionnaire de qualité de vie de l’adulte strabique (AS-20)

A growing number of articles have shown the negative impact of strabismus on self image, relationships with others and professional life. The AS-20 is a standardized questionnaire in English measuring the psychosocial impact of strabismus in adults. The goal of this study is to validate the AS-20 in the French language. Three hundred and ninety one patients took part in the study: 131 had strabismus (group 1), 128 other ocular diseases (group 2) and 132 "normal" patients (group 3). The AS-20 scale showed good psychometrical properties in 2 or 4 dimensions: internal consistency was very good (Cronbach's alpha coefficient>0.9 in all dimensions and overall) and the reproducibility was satisfactory (intra class coefficient>0.7). The comparison of the scores in the 2 dimension scale showed significant differences between the groups (P<0.001): lower score in strabismus (63.9±18.3) than in other ocular diseases (73.5±17.8) and normal group (89.4±12.0) (divergent validity). The 4 dimension psychometric analysis was performed by removing 2 items and grouping the 18 others in 4 groups. It confirmed the divergent and convergent validity, internal consistency and reproducibility of the scale. The results of the confirmatory factor analysis were better with the 4 dimension scale than the 2 dimension scale (adjustment coefficients>0.9). We now have access to a health related questionnaire in French to quantify the impact of strabismus on quality of life and measure the results of treatment.